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CMS offers temporary fire sprinkler citation fix

November 19, 2013
by Pamela Tabar, Editor-in-Chief
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The Centers for Medicare & Medicaid Services (CMS) has issued a new memo proposing several mitigation actions for nursing homes that are in the process of installing fire sprinklers. If facilities can comply with the list of tasks during sprinkler installation, CMS will ease the survey citation level from the D-F range to a C.

The memo attempts to ease the burden on facilities that are in mid-installation, since the installation process is often out of a facility’s control. “Examples include the capital outlay, the need to move affected residents carefully during construction, the nature of fire risk, dependence on other entities with their own action schedules (e.g., local authorities granting required construction permits, construction companies), and others,” the memo states. “In rare cases CMS may find that the demonstrated application of such extraordinary protections, together with only a short exposure period of time before full sprinkler status is achieved, has so reduced the fire injury risk that no more than a potential for minimal harm remain.”

These “extraordinary protections” involve either evacuating residents from the unsprinklered area until the proper system installations are completed, or achieving a 10-point list of preventative actions, including staffing a 24/7 fire watch, providing extra staff training and conducting regular fire drills. Only buildings constructed of certain materials qualify for the latter option.

As of new November 2013 data, the number of unsprinklered or partially sprinklered facilities has dropped from 1,260 to 928 since the August CMS reporting.

The CMS memo also eased the penalty parameters for fully sprinklered or partly sprinklered facilities with citations, changing the language from requiring absolute compliance within a specific compliance cycle to requiring “substantial compliance” to avoid statutory penalties.

Related story: Fire safety compliance still troubles SNFs, deficiencies loom